Regional determinants of quality of care for sick children: A multilevel analysis in four countries

Background The limited impact of increased access to care on improvements in health outcomes during the Millennium Development Goal era has been attributed, in part, to inadequate quality of care. We identified regional factors associated with health service quality for sick child care in low-income countries and examined whether provider factors interact with regional factors to affect the quality of care. Methods We conducted cross-sectional random intercept four-level linear regression using the most recent Service Provision Assessment and Demographic Health Survey data from four countries (467 from the Democratic Republic of Congo 2018, 2425 from Afghanistan 2018, 2072 from Nepal 2015, and 813 from Senegal 2017). The outcome variable was the service quality score for sick child care, which was measured as the percentage of clinically recommended tasks completed in the integrated management of childhood illness (ranging from 0 to 100). Regional factors were selected based on the High-Quality Health System Framework. Results The service quality score was found to be positively associated with the proportion of large facilities (β = 8.61; P = 0.004) and the proportion of providers ranked in the top fifth for service quality score (β = 30.15; P < 0.001) in the region. We identified significant cross-level interactions between provider qualifications (β = −16.6; P < 0.001) or job descriptions (β = 12.01; P = 0.002) and the proportion of providers in the top fifth for service quality scores within the region. As the proportion of top-performing providers in a region increased, the increase in the service quality score was more pronounced among providers who were nonmedical doctors or did not have job descriptions than among their counterparts. Conclusions Our findings indicate that the quality of care for sick children in a region improves with a greater proportion of high-performing providers or larger facilities. Providers who are not medical doctors, or those who have specific job descriptions, tend to benefit more from the presence of these top-performing providers.


eAppendix1. Hypothesized pathways by which factors at different levels may affect the service quality for sick child care
Since health services are delivered by providers, provider characteristics such as provider's sex, qualification, having job description or updated training will directly influence the quality of health service they offer (Barber, Bertozzi, & Gertler, 2007;Hansen et al., 2008;Leslie, Gage, Nsona, Hirschhorn, & Kruk, 2016;Sato et al., 2017;Soeters, Habineza, & Peerenboom, 2006).They also may indirectly affect service quality by influencing the characteristics of the facility where they work, for example by demanding that the facility introduce specific procedures or rules of operation.Although children are direct beneficiaries of health services, caregivers are the ones who make decision on utilization of services and assess the effectiveness (Pariyo, Gouws, Bryce, & Burnham, 2005).They may complain to provider or facility about the quality of the service they received, and ask for better care for their sick child.They can also have an impact on the health service quality by urging the local government to invest more in health service or by exercising their right to vote.We included a caregiver's age, education level, relation to the sick child and the severity of child illnesses as factors related to this.Health service quality depends on the provider incentives inherent to facility type or level and governance of a facility.Region characteristics might affect the service quality from a macro perspective.We constructed the region-level variables based on the five sub-domains in the foundation in the "High-Quality Health System" framework suggested by the Lancet Global Health Commission: population and their health needs, governance of the health sector, platforms for health care delivery, workforce, and tools such as medicine and equipment (Figure 1) (Kruk et al., 2018).
Empowered women raise a voice for better service to providers, facilities, or to government (Lewis, Ndiaye, Manzi, & Kruk, 2022).In more densely populated areas, information sharing will more actively occur, and hence, people's feedback on service quality would be more immediate.
Previous studies have shown that high level of ethnic diversity is associated with poor governance, especially in terms of public good provision.In ethnically-heterogenous communities, the perceived value of a particular health service relative to other services is likely to differ due to cultural variation.Additionally, conflict between ethnic groups is frequent because they represent the interests of their own ethnic group (Habyarimana, Humphreys, Posner, & Weinstein, 2007).Ethnic diversity, on the other hand, may offers advantages as well.
Large facilities, including hospitals and large health centers, may offer technical support to lowerlevel facilities.Private facilities might trigger more competition among facilities for better care (Zelder, 2000).The composition of the workforce in the region can impact the service quality through spillover effects from better-performing providers to others by sharing knowledge and experience among peers (Wong, McNamara, & Greenberg, 2004).Specifically, medical doctors (MD) (or quasi-MD) can teach other less-qualified health workers.A high proportion of topperforming providers in the region means that there are many exemplary providers who other providers can benchmark.Better tools allow providers to be able to perform more diagnostic tests or treatments (Figure 1).

eAppendix2. SPA dataset
SPA consists of four distinct modules; facility audits to collect data on available infrastructure, health provider interviews, direct observation of protocols for different types of care (ex.antenatal care, sick childcare, or family planning) to assess process quality, and finally, an exit interview with caregivers to assess their satisfaction with the service and examine demographic characteristics.For process quality for sick childcare, patients presenting for sick childcare were sampled within each sampled health facility, and consultations for them were observed and assessed by trained observers.

Nepal
Nepal is divided into five development regions, 14 administrative zones and 75 districts prior to the promulgation of a new constitution in 2015.Developmental region was creased to promote national unity by removing regional imbalances and also by utilizing the natural resources of the mountains and hills in a proportional manner.All developmental regions are under direction and supervision of their regional headquarters. 4  DR Congo DR C ongois divided into the capital city of Kinshasa and 25 provinces, and 145 territories.Provinces have both an executive body with a leader and a deliberative body which was to elect the leader. 5*SPA: Service Provision Assessment

Table S1 .
Recommended tasks in Integrated Management of Childhood Illnesses (IMCI) used to construct the technical quality score of sick childcare • Provider asked about mother's HIV* status if child received vitamin A within past 6 months if child received any deworming medication in last 6 mon.

Table S2 .
Detailed information on the region in each countryCountryAdministrative levelsSenegalSenegal is composed of 14 regions, 45 departments, and 103 arrondissements.1The14 regions are administered by a Conseil Régionaux, which is elected by population weight at the arrondissement level.Department has no independent political and arrondissement is purely administrative structure. 2

Table S4 .
Missing rate at each level overall and by country *MD: Medical Doctor/:** IMCI : Integrated management of childhood illness

Table S6 .
Descriptive statistics of analytic sample by country